HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 976 TURNPIKE STREET 5/18/2020 Commonwealth of Massachusetts `
City/Town of Of 16 620
System Pumping Record j „ 14 OFNOR f H „ER
Form 4 t4z&1H DEPART
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left ight rear of hous , Left/right side of house, Left
Right side of building, Left/Right front of building, a Rig rear of buildtng, Under deck
0wrown �— State Zip Code
2. System Owner.
Name'
Address(if different from location)
CilylTown stag a
Telephone Number
B. Pumping Record
1. Date of Pumping gate 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑-V9 ❑ No If yes, was it cleaned? No
5. Condition of System
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati contents-were disposed:
G_ S Lowell Waste Water
-Mi S- A P-)
Signk4e 9t HbulerU Date
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